Neurotraumatology of The Spine

Spinal injury is a particularly  frequent  in young people especially after motor vehicle accidents or falling from heights.

The injuries may be a wedge shaped deformation (compression fracture) of a vertebral body, a burst fracture of the vertebra with pressure on neural structures, a fracture-dislocation at the fracture level with associated semi-transection or transection  of  the spinal cord or cauda equina and finally Spinal epidural and/ or subdural and/or intraspinal cord hematoma may occur as well as the possibility of intraspinal contusions and swelling.

Symptoms can range from pain in the injured area which extends to the limbs, paresthesias or dysesthesias of the extremities and torso (depending on the location of the lesion) to monoparesi, monoplegia, hemiparesis, hemiplegia, paraparesis, tetraparesis and tetraplegia which is a severe clinical manifestation of a cervical spine injury.

 A complete physical and neurological examination is performed followed by diagnostics  initially X-Rays, followed by CT and MRI of the injured spine.

Depending upon the findings of the clinical examination and neuroimaging the further treatment of the injured is determined. Treatment may be simple support of vital signs, antiedemic and/or surgery to decompress the neural structures and the stabilize the spine.

More specifically for the stabilization of a simple compression fracture there is a choice of conservative rehabilitation with  bed rest for at least 3-4 weeks or, either  vertebroplasty or kypholasty aimed at the immediate mobilization of the patient, pain management and stabilization - reduction of the fracture.

In case of a burst fracture of the vertebral body the neural structures which are usually  compressed  by  the fracture  have to be decompressed and spinal fusion  performed to stabilize the spine.

The fracture-dislocation is an extremely urgent neurosurgical condition because of the severe clinical picture usually displayed by injured. Immediate decompression of the neural structures, restoration of normal spinal structure and stabilization with spinal fusion is required. Hematomas of the spine depending on the clinical and neurologic picture are treated either conservatively or surgically. Drainage of the hematoma depending on the intensity and preferred access point may require stabilization with fusion.

A period of 6 hours is critical in order to address the pressing injuries of the spine to the spinal cord. Beyond this "window period", the neurological signs may most probably not be able to be reversed and become permanent resulting in huge socioeconomic costs to the patient's family and society.

In cases of intraspinal contusion and swelling, careful monitoring with regular neurological check-ups  is advised  for early diagnosis of  deterioration and neuroimaging diagnostic testing of the findings  and / or regular monitoring  of the image changes of the lesions.

Another pathological condition which may also be traumatic is the automatically pathological osteoporotic fracture which usually occurs after a relatively routine activity in older patients and more commonly women. There is one permanent treatment, vertebroplasty or kyphoplasty.

Tumors of The Spine

Structure of the Spine
The structure of the spine is complex and includes bone, muscle, intervertebral discs, ligaments, joints and nerves. Of these, the vertebrae and spinal cord are the most important for a better understanding of tumors that develop in these areas.

Vertebrae: The spinal column consists of 32-34 small bones, which are aligned one above the other, including the sacrum and coccyx. Most adults have 7 cervical vertebrae, 12 thoracic and 5 lumbar. The sacrum and coccyx are a total of 8-10 fused vertebrae. Each vertebra has a hole in its center. The aligned holes form a channel (spinal canal), which encloses and protects the spinal cord and the spinal nerve roots which branch off it.

Structure of the Spinal Cord

The spinal cord is a long column of nerve fibers that carries messages to and from the brain. It extends from the base of the skull down to the first lumbar vertebra, where it tapes to form the medullary cone. It continues until the sacral area and coccyx as thin connective tissue, the final filament. The length of the spinal cord is about 65 cm and its diameter varies with the height of the vertebral column and is about the thickness of the thumb. At its center is the central canal which is soaked in cerebrospinal fluid. The peripheral or spinal nerves exit from there. As the spinal cord reaches the height of the first lumbar vertebra, the lower nerves extend for a distance in the spinal canal, to exit, forming a structure resembling a horse's tail, the cauda equine.The spinal cord & cauda equine are surrounded by three layers of meninges (dura, arachnoid and pia), which form the meningeal sac. Cerebrospinal fluid circulates in the space between the arachnoid and dura mater (subdural space). Toothed link lateral denticulate ligaments extend throughout the length of this area. The space between the dura and the vertebrae is called the epidural space and contains fat and vessels. Structurally, the spinal cord consists of 2 parts: The inner layer has a butterfly shape is grey in color (gray matter) and contains the nerve cells and glia as well as blood vessels. The outer layer (white matter) there are nerve fibers (axons) that carry the sensory information, such as pain and sense of judgment, touch, pressure and temperature from the body to the brain and kinetic commands from the brain to the muscles, internal organs and glands.

Tumors of the Spine

Tumors of the spine are relatively rare. They can be either primary (from bone cells) or secondary (metastases from other primary cancer sites). They grow at different rates. In general, malignant tumors grow rapidly, while benign tumors can grow slowly, and often grow for years before causing any symptoms.

Symptoms

The most common initial symptom in patients with such tumors is pain. Back pain is common and not a specific symptom of any disease or physical condition. The pain may be worse at night or on awakening. It can also spread beyond the spine to the hips, legs, or arms and usually worsens over time, despite receiving analgesic treatment. Depending on the location and type of tumor, other symptoms develop, resulting in displacement or in breach of neural structures, vertebrae, blood vessels and intervertebral disc, comprising:

• palsy (muscular weakness) or paralysis (complete inability -disability) that may occur in varying degrees and in different parts of the body, depending on the anatomical location of the tumor
• Difficulty in walking, which may lead to falls
• Difficult to perform subtle movements
• Reduced sensitivity to pain, heat and cold
• Loss of bladder control and / or bowel
• Distortion of the spine

Diagnosis of Spinal tumors

Spinal tumors can sometimes not be detected immediately as they are rare and because their symptoms resemble those of more common diseases. It is extremely important for your doctor be aware of your full medical history and if there is suspicion to schedule diagnostic tests to be done, which are able to confirm the diagnosis and determine the location of the tumor. MRI is the examination of choice, as it is the only test that produces highest resolution images of all anatomical structures of the spine and spinal cord. Computed tomography is sometimes necessary to determine the degree of infiltration of bony structures (vertebrae), and to plan surgery. Often specialized lumbar puncture and CSF examination is required, particularly if demyelinating disease, or myelitis is suspected. Bone scintigraphy is able to determine dispersion, usually metastatic tumors. Simple radiographic examination is the most widely used and easily performed initial diagnostic test. Based on the direct and indirect evidence that are highlighted further neuroimaging tests are scheduled. In some cases CT guided biopsy is proposed performed under isolated-local anesthesia, as this is the only diagnostic test that provides histological identification of tumors, especially tumors of the vertebrae. This is not applicable to intramedullary tumors.


Treatment of Spine tumors

Depending on neuroimaging characteristics of the tumor and histological diagnosis of the biopsy taken from the tumor, further treatment is decided either surgical or radiation and radiosurgery treatment or chemotherapy (usually in metastases¬)
In ideal cases, the treatment goal of a spinal and spinal cord tumor is the total resection of the tumor and restoration of spine stability while protecting the functionality of sensitive nerve structures. Any intervention however carries the risk of permanent neurological damage. To select the most appropriate treatment method the neurological state, age, general health status of the patient, the type and location of the tumor and whether it is primary or secondary (metastatic) tumor are taken into consideration.
Primary spinal cord tumors in adults are mostly benign and develop slowly. They account for 15% of the neoplasms of the CNS. 2/3 of them are extramedullary and usually benign. The more common histological types of tumors are tumors of nerve sheath, ependymomas meningioma, astrocytoma, Filum terminale ependymomas and hemangioblastomas. Treatment options for most tumors include:

Monitoring:

The common signs and symptoms of a tumor of the spinal cord show a typically slowly growing mass and include pain in the back, neck, arm, atrophy or paresis or plegia and corticospinal tract lesions. If the lesion involves the myeloid tergum, the parasympathetic innervation of the bowel and bladder and genital organs are affected. If the lesion is in the cauda equine it can cause selective deduction in the function of a nerve root and a subtle dermatomal correlation of pain with the root.

Often the tumors are diagnosed before they cause symptoms, in random tests done for other reasons. In certain cases, small apparently benign tumors that do not significantly displace sensitive nerve structures, or intramedullary with a high intraoperative risk. Accessible lesions that cause only mild symptoms treated only with monitoring especially in the case of the elderly and in cases where surgery or radiation may cause irreversible damage to neural structures. Monitoring is normally done with MRI at regular intervals, 6-12 month or if symptoms get worse.


Surgical Treatment: This is often the first step in treating tumors that can be removed with an acceptable risk of possible postoperative neurological deterioration. The newer techniques, especially intraoperative neuromonitoring , the use of tumor resection devices which function with ultrasound, microscopes, endoscopes, and micro surgical instruments now allow neurosurgeons to access and completely remove tumors that were previously inoperable. However, even with the implementation of all new technologies, it is not always possible to remove all tumors.

Surgical removal is the best option for many intramedullary and intradural -extramedullary tumors, but tumors like widespread ependymomas, may be impossible to remove completely from the spinal cord or the nerves of the cauda equine. Today we are able to perform surgery with more precision using neuromonitoring and neuronavigation. Neuromonitoring allows us to control intraoperative stimulation and recording from the nerves of the spinal column to minimize the possibility of intraoperative injury to a nerve or the spinal cord itself depending on the level of surgical access.

Neuronavigation allows accurate preoperative localization of the tumor and intraoperative determination of surgical margins in order not to influence the healthy surrounding neural structures. Most benign tumors are usually removed completely, which is not always achieved in metastatic or invasive intramedullary tumors.

Especially for metastatic tumors, the treatment of choice is radiotherapy and only in case of progressive neurological deterioration or instability of the spine surgery is recommended. Rehabilitation after surgery can take weeks or months, during which, often, symptoms are more pronounced, compared with the preoperative state.

Radiotherapy: Can be used after surgery to control the residual disease or to prevent recurrence, or to deal with inoperable tumors. It is treatment of choice for metastatic tumors and is often used as emergency treatment. Radiation can also be used to relieve pain when there is no possibility of cure. Side effects of radiation, such as dizziness and nausea adequately treated with medication. In radiotherapy of the spine targeting techniques are applied and segmentation of the dose over several sessions in order to prevent damage to surrounding tissue and improve the effectiveness of treatment.

Chemotherapy: Chemotherapy has not proved beneficial for most spinal and spinal cord tumors. However, there are exceptions. In some cases chemotherapy is advisable, but always in combination with surgery and / or radiotherapy. It is usually used in metastatic tumors.

 

Abscess

Cerebral abscess is an infection of the brain that is accompanied by headache, fever and / or focal symptoms. The etiology in most cases is due to nearby infection and more rarely from craniocerebral injury and intracranial surgery. The abscess appears more commonly at the grey-white matter junction. The most common organisms responsible for the development of infection are streptococci, staphylococci and anaerobic bacteria, either alone or in combination.

Symptoms

• Headache
• Drowsiness
• Confusion
• Fever
• Speech disorders
• Vomiting
• Fatigue
• Epileptic seizures

The Symptoms and findings depend largely on the specific location of the abscess in the brain. An abscess in the cerebellum, for example, can cause additional side effects such as hydrocephalus and pressure on the brain stem.

It is easily diagnosed by CT scan.

Indications for surgical intervention

Initially conservative therapy is preferred with appropriate chemo-prophylaxis, anti-inflammatory and anti-seizure treatment. If this does not yield the desired and / or expected results, then surgical intervention is imperative. Surgical drainage also offers a permanent solution in cases where the clinical presentation of the patient has worsened.

The treatment depends on the location of the abscess. In the speech, motion or sensory cortex area and deeper lesions stereo-tactic drainage of the abscess and biopsy to obtain specimens for culture to identify the pathogens is preferred.

For abscesses near the cortex and relatively easily accessible areas , craniotomy is preferred to drain the abscess capsule  thus  minimizing the risk of recurrence of the abscess provided that the risk of hemorrhage can be avoided during removal of the capsule .

Hydrocephalus

The term "hydrocephalus" defines the abnormal accumulation of cerebrospinal fluid (CSF) within the normal brain cavities (ventricles of the brain). Hippocrates first mentioned the term "hydrocephalus" in neonates and infants presenting swelling of the head. Normally CSF is produced within the ventricles and then fed either to the base of the skull and spinal canal or to the top of the brain from where it is then drained  to the venous system. The main function of CSF is to protect the brain and spinal cord from contact with the rough inner surface of the skull and spine, both in the movements of our body, and in slight accidents.

Moreover, the CSF regulates the transport of important nutrients to the nervous system, while removing metabolic products from the nervous tissue. The normal brain produces a daily pint of CSF (20 ml / hour), while the fluid pressure ranges from 0-18 cm H2O, depending on the posture and activity of the individual.

Hydrocephalus is a condition in which cerebrospinal fluid (CSF) remains usually under pressure in the ventricles of the brain. The reason is that there is an imbalance between production and absorption of CSF. Hydrocephalus should not be confused with other situations in which the ventricles of the brain  swell due to lack of / deterioration of brain tissue (atrophy) .


Essentially the following mechanisms that can lead to hydrocephalus:

• Obstruction of CSF circulation
• Difficulties in venous outflow and
• Increased production of CSF
• Malabsorption of  CSF

The causes of hydrocephalus are numerous and quite confusing: infectious conditions (encephalitis), brain mass lesions, trauma, degenerative diseases, abuse and a series of unknown factors are considered responsible for its development.

For years now treatment is based on a threefold structure.

• early diagnosis
• Pharmaceuticals and
• surgery

Clinical picture and treatment

The symptoms of hydrocephalus are more evident in very young children. The head circumference grows rapidly with a change in shape of head  especially a prominent forehead  and dilation of the veins of the scalp. Older children display focal symptoms such as headache and vomiting, personality change, oculomotor palsy, spasticity, etc.

Diagnosis is made by combining clinical picture, ultrasound (for newborns) and radiological examinations (X-ray skull, CT and MRI).
Treatment is designed primarily to remove any possible cause of obstruction (tumor, dysplasia) and the most common surgery is the drainage of CSF to balance production with the absorption and removal of CSF.

Hydrocephalus in adults usually associated with space-occupying lesions (tumors, hemorrhages, ischemia, congenital anomalies) and after craniocerebral injuries.

Moreover, Hydrocephalus of low or normal pressure, namely Normal pressure hydrocephalus is found in the elderly, a special form which is considered to be due to increased intracranial pressure and elasticity of brain tissue resulting in permanent swelling of the ventricles. A proportion of patients improved after the insertion of a  ventriculoperitoneal  CSF drainage valve.

The symptoms of adults in more acute situations include, signs of increased intracranial pressure with vomiting, agitation, headache, fatigue, swelling of the optic disc etc. In ‘normal pressure hydrocephalus’ symptoms of dementia, gait and memory disturbances, and urinary incontinence are observed.

The diagnosis is made with a combination of laboratory and imaging tests and treatment is primarily aimed ,as with  children, at removing the possible cause.

In most cases, a regulated a  ventriculoperitoneal  CSF drainage is inserted, while in a limited  percentage of cases an alternative endoscopic procedure called third ventriculostomy can be performed.


There are the following three types of hydrocephalus:

• Primary or idiopathic (unknown cause)
• Secondary,as a result of
• bleeding (subarachnoid or intracerebral)
• injury
• tumor or cyst
• intracranial surgery
• meningitis
• stenosis or blockage of CSK drainage duct
• overproduction of CSF (choroid plexus papilloma)
• Congenital (abnormal mafromations in fetal or neonatal-infantile period)

Also, subject to when it develops  hydrocephalus is classified as acute or chronic.


IDIOPATHIC HYDROCEPHALUS

Idiopathic Hydrocephalus usually occurs in the elderly. In several cases it also occurs in patients with years of alcohol or drug abuse because of the brain atrophy related to  taking such substances. In the process of brain aging in some individuals the normal pathways of CSF drainage to the venous circulation (sagittal upper vagina) block with as result the accumulation of fluid within the ventricles, "chronic" compression of the brain.

In situations such as craniocerebral injuries, hemorrhagic stroke (subarachnoid or intraventricular hemorrhage), tumors or infections (meningitis) normal drainage is disrupted resulting in the accumulation of CSF, increased intracranial pressure and compression of the brain (hydrocephalus secondary). When the compression is acute or subacute (ie it evolves in hours, days or weeks) the victim has persistent headache, vomiting, reduction of vision (oculomotor palsy), unstable posture, gait, confusion, sleepiness, drowsiness or coma . In contrast, chronic accumulation of excess fluid is absorbed by the brain itself but with some stress in neuronal function and perfusion.


SYMPTOMS:

• memory loss ("amnesia"), particularly in recent
• difficulty in walking (small, slow steps or instability with frequent falls or a complete lack of posture and gait-instability )
• frequent urination, urgent urination or incontinence.

This situation is sometimes confused with senile dementia, premature aging or cerebral atrophy, a common form of which is Alzheimer disease. Hydrocephalus of the elderly initially displays mobility disabilities, often confused with Parkinson's disease.


DIAGNOSIS

CT scan, which shows the dilatation of the ventricles is used to diagnose idiopathic hydrocephalus, which usually occurs after the age of 65.

Today we have other diagnostic tests (magnetic resonance imaging, puncture and measurement of pressure in the brain, measurement of the CSF drainage and temporary, neuropsychological testing, gait analysis videoscope)to use where the CT is not conclusive and does not help the diagnosis.


Treatment
When you definitively diagnose hydrocephalus in the elderly (the medical term is "Idiopathic normal pressure or" Hydrocephalus), then CSF bypass surgery is proposed.A system of narrow silicone tubes are placed under the skin which have an intermediary valve that regulates drainage of fluid. The one end of the tube is placed in the ventricles of the brain and the other to the free peritoneal cavity of the abdomen. The peritoneal cavity has the capacity to absorb CSF. When the proper patient selection criteria is followed, surgery is highly effective and improvement of memory, gait and continence particularly remarkable for the patient and immediately recognizable by their relatives.


History of  Hydrocephalus valves

The first attempts of CFS  bypass surgery were performed in the early 20th century with rubber tubing or artificial opening pathways
within the brain cavity (ventricular system) using an endoscope.

Today the pressure valves we use have their pressure programmed by special ultrasound machine and do not require surgical replacement.

Brain Aneurysm

Causes, Warning signs and Symptoms

 A brain aneurysm is defined as any abnormal enlargement or dilatation of the lumen of a cereb  ral artery. The cerebral aneurysms according to their morphology identified as Saccular and Fusiform,and the most common form is Saccular. In other words a sac is formed at a weak point in the artery with a stem which joins it to the rest of the artery. They usually develop in arterial junction areas. In a Fusiform brain aneurysm, the aneurysm takes a long narrow shape which includes all the wall of the artery on both sides. The size and the anatomical position of the aneurysm are the factors which usually define the clinical manifestation. Usually the rupture of the aneurysm manifests with subarachnoid hemorrhage (SAH) and more often with intraventricular hemorrhage or intraparenchymal.

 The Symptoms of a ruptured aneurysm are:

• Severe unprecedented headache
• Stiff neck
• Vomiting
• Photophobia
• Diplopia
• Pain in eye
• Drooping eyelids
• Disturbance- deterioration in level of consciousness
• Palsy or paralysis of a cranial nerve
• Pupil dilation
• Numbness, paresthesias dysesthesias of half of the face

Non ruptured aneurysms are accompanied by focal neurological signs (reduced visual acuity, ophthalmology, psychology and cognitive disorders etc.) or with epileptic seizures. Often preceding minor leaks of the aneurysm cause persistent headache.

Demographic data:

 The incidence of subarachnoid hemorrhage (SAH) is 1:10.000 residents annually. Based on this figure, for Cyprus, approximately 100 patients are expected annually. In 80-90% of these patients the subarachnoid hemorrhage (SAH) is caused by ruptured aneurysm, while 5% by rupture arteriovenous malformation. While at a rate of 10% -20% no pathology is found, the SAH may be due to coagulopathy, thrombocytopenia, leukemia, vasculitis, or neoplasms and vascular diseases of the spine.

Postmortem studies have shown that the incidence of cerebral aneurysms in the general population is 2 % while half of these will occur with rupture of the aneurysm that occurs between the ages of  45 and 65. The majority of aneurysms, 80%, are less than 1 cm in size. In most cases however, there is either a family history of aneurysm or a congenital abnormality in the arterial wall.

With regards to the hereditary correlation it has been proved that there is a 10-15% chance of the development of a cerebral aneurysm among first degree relatives. Hence the extreme importance of precautionary screening with digital subtraction angiography or non-invasively by three-dimensional angiography or MRA. The same diagnostic procedure is applied to determine the existence of an aneurysm in cases of subarachnoid hemorrhage. In some cases the aneurysm showed up randomly in a screening by CT or MRI brain performed for another indicated disease.

About 20% of patients with a ruptured cerebral aneurysm die before they reach a hospital while 20% with ruptured cerebral aneurysm have a severe clinical picture which negatively affects both the outcome and rehabilitation of patients. The remaining 50-60% of patients tested are in relatively good neurological condition and able to undergo timely treatment of the aneurysm with a metal staple. This procedure excludes the possibility recurrence of hemorrhage and development of cerebral ischemia due to vasospasm.

Aneurysm Treatment:

The most contemporary non-invasive method of treatment for aneurysms is that of embolization of the aneurysm.

Microcatheters are inserted usually through the femoral artery and navigated to the area of the aneurysm and special coils are placed in the sac which helps block the flow of blood into the aneurysm. In many cases it is necessary to use special expandable stent catheters which ensure the anatomical structure of the vessel.

If however embolization of the aneurysm is not possible, surgical clipping must be performed with aneurysm clips to prevent blood flow into the aneurysm and new rupture of the aneurysm.

Factors that increase the risk of formation of a brain artery aneurysm are:

• Smoking
• High blood pressure
• Drug abuse, cocaine in particular
• Brain Tumors
• Infections
• Family history of brain aneurysms
• Head trauma
• Congenital brain aneurysm due to abnormalities in the arterial wall
• Dysgenesis of the circulatory system of the brain such as arteriovenous malformation
• Inherited conditions such as polycystic kidney disease, Marfan syndrome,Ehler’s syndrome

Arteriovenous malformations:

These are a cluster of abnormal blood vessels where the arteries flow directly without the intervention of capillaries and veins and without brain parenchyma  present in the "nest" of the cluster. These are congenital lesions that gradually increase in size. They are usually diagnosed due to:

• Bleeding
• Epileptic seizures caused by ischemia
• Persistent headache
• Symptoms indicative of increased intracranial pressure (ICP)

If hemorrhage or dysplasia is also present there is a 10% mortality rate per episode of hemorrhage and 30-50% chance of neurological deficit per episode of hemorrhage. The bleeding is intraparenchymal  less frequently spontaneous subarachnoid, or intraventricular  or spontaneous subdural hematoma.

These dysplasias are evaluated according to the size, the location in relation to structures and their venous drainage.

Therapy:

Usually endovascular embolization is preferred followed by radiotherapy or stereotactic radiotherapy for small lesions less than 3 cm or conventional radiotherapy in larger lesions. The surgical treatment of dysplasias eliminates the risk of hemorrhage immediately and improves the control of epileptic seizures.